Gastroesophageal Reflux Disease and Hiatal Hernias

Many people suffer from heartburn or GERD. This can be treated medically, however some people are candidates for a minimally invasive (laparoscopic) surgery. This procedure may ultimately allow a person to stop taking many medications which are used to treat reflux or heartburn.

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Gastroesophageal Reflux Disease (GERD)

GERD is a digestive system disorder that affects the esophagus. If you have GERD, your stomach acid and contents persistently flow back up through your esophagus.
10-20% of the US population has GERD
A hiatal hernia is sometimes found and can predispose you to reflux (see section below).

Symptoms

Heartburn, pain in the upper abdomen/chest after eating
Regurgitation is feeling of stomach contents coming back up into your mouth/throat after you have swallowed

Common tests

Upper GI (or swallow study). This is often used to evaluate a hiatal hernia
EGD (upper endoscopy). This is usually how your reflux is first evaluated. This can show inflammation of your esophagus, evaluate for precancerous changes and rule out other diseases
pH testing. This is used to determine how often you have acid reflux, and how much your symptoms correlate to the acid. This is sometimes used to determine how well you may respond to surgery.
Manometry. This measures the pressure in your esophagus and can help guide surgical decision making or rule out other issues.
CT – may be used in addition for specific indications

Treatment Options

Medical management
- Typically, GERD is treated with lifestyle changes and medications first. This includes, elevating the head of your bed, avoid eating late at night, avoid triggering foods, avoid alcohol and tobacco, weight loss.
- Medications are given if this does not control your GERD. These medications decrease the acid in your stomach, or help to protect/heal it
Surgery
- Laparoscopic Nissen fundoplication is currently the ‘gold-standard’ for treating GERD in patients who don’t respond completely to medications or can’t or are not willing to take medications long term.
- Laparoscopic Nissen fundoplication is the most commonly performed antireflux procedure.
- If you are obese and your BMI >35, a roux-en-Y gastric bypass is typically the surgery of choice, as it has better outcomes for these patients. This will be discussed in more detail with your surgeon. Please visit our Bariatrics section for more information.

Laparoscopic Nissen Fundoplication

5 small incisions with hollow tubes placed to use instruments and a lighted camera
Carbon dioxide is used to make space between your organs to work with small instruments
Your stomach attachments are freed near your esophagus
The top of the stomach is wrapped around the bottom of the esophagus. Another term for the fundoplication is a ‘wrap’. This essentially repairs the valve at the end of the esophagus that doesn’t work properly in patients with GERD.
If a hiatal hernia is present, this is fixed at the same time as the Nissen fundoplication (see below)

Hiatal Hernia

Hiatal hernia occurs when part of the stomach and sometimes other organs of the abdominal cavity slide upward through an opening in the diaphragm into the chest cavity.
Normally, the opening in the diaphragm only contains the lower part of the esophagus. When the muscle of the diaphragm weakens, the opening becomes large enough to allow the stomach to slide up into the chest cavity.
This results in symptoms of heartburn, regurgitation, difficulty swallowing, or chest pain.
With time, and if left untreated, constant exposure of the esophagus to stomach acids may cause chronic inflammation (esophagitis), ulcers, and scarring of the esophagus.
If large enough, your stomach may twist and cause obstruction or even loss of blood flow

Treatment

Recommended treatment varies by the type and size of your hernia
Medical treatment of the reflux caused by a hiatal hernia is sometimes all that is needed
The hernia itself will not resolve without surgery

Hiatal Hernia Repair

5 small incisions with hollow tubes placed to use instruments and a lighted camera
Carbon dioxide is used to make space between your organs to work with small instruments
The attachments to your stomach and diaphragm are freed.
Your organs are pulled back down into your abdominal cavity and the hernia sac is removed
Your diaphragm is sutured back together (sometimes with an addition of mesh), to the size of your esophagus
A Nissen or Toupet fundoplication “wrap” is then performed
In fundoplication, the top portion of the stomach (fundus) is wrapped around the esophagus to create a pressure area and prevent the contents of the stomach from backing up into the esophagus (acid reflux).

Risks

Bleeding, infection, damage to surrounding structures
Dysphagia (difficulty swallowing) or bloating
Slipped wrap
Conversion to open procedure (large incision) <1%.
Anesthesia-related risks (heart, lung complications and blood clots)
Your risk of complications depends on your overall health, previous medical conditions, and previous surgeries

Results

Most patients quality of life is significantly improved after surgery for GERD
GERD-related symptoms reliably resolve in a high percentage of patients after surgery
Most patients are able to stop taking acid-suppression medications
Most patients are satisfied with the results of surgery (>90%)
Most patients are discharged from the hospital the day after their surgery and return to a normal lifestyle in 2-4 weeks
Bloating and dysphagia (difficulty swallowing) can occur after surgery. These typically improve/resolve with time

What to expect

Preparing for your surgery

Nothing to eat or drink after midnight the night before your surgery
You may take am meds (you will be told which ones to take/hold) with a sip of water in the am
If you smoke; quitting smoking before surgery can decrease your risk of respiratory complications and infections after surgery.

Day of Surgery

You will receive general anesthesia and have breathing tube (endotracheal tube) put down during surgery. You will be completely asleep for this and the tube is removed before you wake up. The anesthesia provider will meet with you the morning of surgery
You will stay overnight, and most likely go home the day after your surgery
You may have a test done (Upper GI) the morning after surgery to evaluate the repair before your diet is advanced

Postoperatively

It is normal to have pain, especially in your shoulder/neck and with deep breathing. This is from the gas used during surgery and will resolve within a couple days. Changing positions can help.
You will be sent home with pain medications which most people will take for a few days after surgery then are able to wean to non-narcotic mediations
Hycet (the narcotic most commonly prescribed) has Tylenol in it. Either take hycet OR Tylenol, but not both together.
Walk around as able. Take deep breaths to fully expand your lungs. This can help prevent pneumonia and blood clots
Slowly increase your activity. You are typically ready for normal activity by 1-3 weeks after your surgery.
Most people will be able to return to work or school about 1-2 weeks after surgery.
Wound care
- All sutures used will be buried under the skin and absorbable.
- If you have steri strips over your incisions. Remove bandaids in 24-48hrs after surgery. Leave white strips (steri strips) in place and shower. Let soapy water run over these and pat dry. They will begin to peel off in about 7-10 days then you may remove.
- If you have skin glue (dermabond) over the incisions you may shower immediately. When this begins to flake off you may peel off, typically in a week.
- Do not bathe, soak incisions, go in hot tube, pool or lake/ocean for 2 weeks. o Your scar with heal over the next 4-6 weeks and continue to fade and soften over the next year. Use sunscreen over incisions when exposed to sun for the next year.
Diet
- After surgery, it is common to have some difficulty swallowing, of feeling like food
  “gets stuck” at the area of the repair. This is typically dues to swelling of the repair and improves/resolves over the next days to weeks
- General Principles
  - Keeping the stomach from stretching
    - Eat small, frequent meals to prevent your stomach from stretching. We recommend eating 6 times per day, or every 2 to 3 hours.
    - Eat foods that are easy to swallow and digest. These usually consist of soft, moist foods such as soup, gelatin, pudding, and yogurt. Avoid gummy foods such as bread and tough meats.
    - Take small bites, chew your food well, and avoid gulping. This helps prevent gas build-up and aids in swallowing.
    - Use a blender to puree foods, such as soup or fruit, to a tolerable consistency.
    - To preserve nutrients when cooking foods, steam or microwave vegetables. When boiling potatoes, peel after cooking.
  - Avoiding Gas
    - Avoid drinking through a straw. Do not chew gum or tobacco. These actions cause you to swallow air, which produces excess gas in your stomach. Chew with your mouth closed.
    - Avoid any foods that cause stomach gas and distention. These foods include corn, dried beans, peas, lentils, onions, broccoli, cauliflower and any food from the cabbage family.
    - Avoid carbonated drinks, alcohol, citrus and tomato products.
  - You will need extra fluids throughout the day to meet your fluid needs.
When will I be able to eat a soft diet?
- After Nissen fundoplication surgery, your diet will be advanced slowly by your surgeon.
- Generally, you will be on a clear liquid diet for the first few meals.
- Then you will advance to the full liquid diet until 2 weeks postoperatively
- Then you advance to a Nissen soft diet until 6 weeks postoperatively
- Please be aware that each patient’s tolerance to food is different. Your doctor will advance your diet depending on how well you progress after surgery.
- If you are not tolerating your level; go back a level and call the office
Clear Liquid Diet
- Apple juice
- Cranberry juice
- Grape juice
- Chicken broth
- Beef broth
- Flavored gelatin (Jell-O®)
- Decaf tea and coffee
- Caffeinated beverages are permitted based on tolerance
- Popsicles
- Italian ice
- Carbonated drinks (sodas) are not allowed for the first six to eight weeks after surgery. Discuss with your surgeon if/when to re-introduce this (if at all)
Full Liquid Diet
- The full liquid diet contains anything on the clear liquid diet, plus:
- Milk, soy, rice and almond (no chocolate)
- Strained creamed soups (no tomato or broccoli)
- Vanilla and strawberry-flavored ice cream
- Sherbet
- Blended, custard styled or whipped yogurt (plain or vanilla only)
- Vanilla and butterscotch pudding (no chocolate or coconut)
- Nutritional drinks including Ensure®, Boost®, Carnation Instant Breakfast® (no chocolate flavored)
- Note: Dairy products, such as milk, ice cream and pudding, may cause diarrhea in some people just after surgery. You may need to avoid milk products. If so, substitute them with lactose-free beverages, such as soy, rice, Lactaid® or almond milks.
Nissen Soft Diet

Food Category	Choose	Avoid
Beverages	• Milk, such as whole, 2%, 1%, non-fat, or skim, soy, rice, almond. • Caffeinated and decaf tea and coffee. • Powdered drink mixes (in moderation). Non-citrus juices (apple, grape, cranberry, or blends of these). • Fruit nectars. • Nutritional drinks including Boost®, Ensure®, Carnation Instant Breakfast®.	• Chocolate milk, cocoa, or other chocolate-flavored drinks. • Carbonated drinks. • Alcohol. • Citrus juices like orange, grapefruit, lemon, and lime.
Breads	• Toasted bread. • Pancakes, French toast, and waffles. • Crackers (saltine, butter, soda, graham, Goldfish® and Cheese Nips®).	• Untoasted bread, bagels, Kaiser and hard rolls, English muffins. • Crusty breads. • Fresh, doughy breads such as sweet rolls, coffee cake, and doughnuts. • Crackers with nuts, seeds, fresh or dried fruit, coconut, or highly seasoned (garlic or onion-flavored).
Cereals	• Well-cooked cereals such as oatmeal (plain or flavored). • Cold cereal (Cornflakes®, Rice Krispies®, Cheerios®, Special K® plain, Rice Chex® and puffed rice).	• Very coarse cereal such as bran or shredded wheat. • Any cereal with fresh or dried fruit, coconut, seeds, or nuts.
Potatoes and Starches	• Peeled, mashed, or boiled white or sweet potatoes. • Oven-baked potatoes without skin. • Well-cooked white rice, enriched noodles, barley, spaghetti, macaroni, and other pastas.	• Fried potatoes, potato skins, and potato chips. • Hard and soft taco shells. • Fried, brown, or wild rice.
Eggs	• Poached, hard-boiled, or scrambled.	• Fried and highly seasoned eggs (deviled eggs).
Vegetables	• Well-cooked soft vegetables without seeds or skins (asparagus tips, beets, carrots, green and wax beans, chopped spinach, tender canned baby peas, squash, pumpkin).	• Raw vegetables. • Gas producing vegetables (broccoli, Brussel sprouts, cabbage, cauliflower, onions, corn, cucumber, green peppers, rutabagas, turnips, radishes, sauerkraut). • Tomatoes, tomato juice, tomato sauce, andV-8® juice. • Dried beans, peas, and lentils.
Fruits	• Fruit juice. • Any canned or cooked fruit except those to avoid.	• All fresh fruits such as citrus, bananas, and pineapple. • Canned pineapple. • Dried fruits such as raisins and berries. • Fruits with seeds such as berries, kiwi, and figs.
Meat, Fish, Poultry, and Dairy Products: Eat ground, minced, or chopped meats to ease swallowing and digestion.	• Tender, well-cooked, moist cuts of beef, chicken, turkey, and pork. • Veal and lamb. • Flaky, cooked fish. • Canned tuna. • Cottage and ricotta cheeses. • Mild cheeses such as American, brick, mozzarella and baby Swiss. • Creamy peanut butter. • Plain custard or blended fruit yogurt. • Moist casseroles such as macaroni and cheese, tuna noodle. • Grilled or toasted cheese sandwich.	• Tough meats with a lot of gristle. • Fried, highly seasoned, smoked and fatty meat, fish, or poultry (frankfurters, luncheon meats, sausage, bacon, spare ribs, beef brisket, sardines, anchovies, duck, and goose). • Chili and other entrees made with pepper or chili pepper. • Shellfish. • Strongly flavored cheeses such as sharp and extra sharp cheddar and cheese containing peppers or other seasonings. • Crunchy peanut butter. • Yogurt with nuts, seeds, coconut, strawberries, or raspberries.
Soups	• Mildly flavored meat stocks. • Cream soups made from allowed foods.	• Highly seasoned and tomato-based soups. • Cream soups made with gas producing vegetables such as broccoli, cauliflower, onion, etc.
Fats: Eat in moderation.	• Butter and margarine. • Mayonnaise and vegetable oils. • Mildly seasoned cream sauces and gravies. • Plain cream cheese. • Sour cream.	• Highly seasoned salad dressings, cream sauces, and gravies. • Bacon, bacon fat. • Ham fat, lard, salt pork. • Fried foods. • Nuts.
Desserts: Eat in moderation. Do not eat desserts or sweets by themselves.	• Plain cakes, cookies, and cream-filled pies. • Vanilla and butterscotch pudding or custard. • Ice cream, ice milk, frozen yogurt, and sherbet. • Gelatin made from allowed foods. • Fruit ices and popsicles.	Desserts containing chocolate, coconut, nuts, seeds, fresh or dried fruit, peppermint, or spearmint.
Sweets and Snacks: Use in moderation. Do not eat large amounts of sweets by themselves.	• Syrup, honey, jelly, and seedless jam. • Molasses. • Plain hard candies and other candy made from allowed ingredients. • Marshmallows. • Thin pretzels.	• Jam, marmalade, and preserves. • Chocolate in any form. • Any candy containing nuts, coconut, seeds, peppermint, spearmint, or dried or fresh fruit. • Popcorn, potato chips, tortilla chips. • Soft or hard thick pretzels such as sourdough.
Miscellaneous	• Salt and spices in moderation. • Mustard and vinegar in moderation.	• Fried or highly seasoned foods. • Coconut and seeds. • Pickles and olives. • Chili sauces, ketchup, barbecue sauce, horseradish, black pepper, chili powder, and onion and garlic seasonings. • Any other food or strongly flavored seasoning, condiment, spice, or herb that you can’t tolerate.

When to Call

Severe or worsening uncontrolled pain
A fever >101.3
Continuous vomiting
Foul smelling drainage, redness or continued bleeding from an incision sites
Chest pain or trouble breathing (call 911 or go to the ER)
Any questions or concerns

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